Clinical guidelines for postpartum women and infants in primary care-a systematic review.

Ha ran et al. BMC Pregnancy and Childbirth 2014, 14:51
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Pregnancy & Childbirth

RESEARCH ARTICLE Open Access

Clinical guidelines for postpartum women and
infants in primary care-a systematic review

Crishan Haran, Mieke van Driel, Benjamin L Mitchell and Wendy E Brodribb*

Abstract

Background: While many women and infants have an uneventful course during the postpartum period, others
experience significant morbidity. Effective postpartum care in the community can prevent short, medium and
long-term consequences of unrecognised and poorly managed problems. The use of rigorously developed,
evidence-based guidelines has the potential to improve patient care, impact on policy and ensure consistency of care
across health sectors. This study aims to compare the scope and content, and assess the quality of clinical guidelines
about routine postpartum care in primary care.

Methods: PubMed, the National Guideline Clearing House, Google, Google Scholar and relevant college websites were
searched for relevant guidelines. All guidelines regarding routine postpartum care published in English between 2002
and 2012 were considered and screened using explicit selection criteria. The scope and recommendations contained in
the guidelines were compared and the quality of the guidelines was independently assessed by two authors using the
AGREE II instrument.

Results: Six guidelines from Australia (2), the United Kingdom (UK) (3) and the United States of America (USA) (1), were
included. The scope of the guidelines varied greatly. However, guideline recommendations were generally consistent
except for the use of the Edinburgh Postnatal Depression Scale for mood disorder screening and the suggested time
of routine visits. Some recommendations lacked evidence to support them, and levels or grades of evidence varied
between guidelines. The quality of most guidelines was adequate. Of the six AGREE II domains, applicability and
editorial independence scored the lowest, and scope, purpose and clarity of presentation scored the highest.

Conclusions: Only one guideline provided comprehensive recommendations for the care of postpartum women and
their infants. As well as considering the need for region specific guidelines, further research is needed to strengthen the
evidence supporting recommendations made within guidelines. Further improvement in the editorial independence
and applicability domains of the AGREE II criteria would strengthen the quality of the guidelines.

Keywords: Postpartum care, Clinical guidelines, AGREE II, Maternal health, Infant health

Background

Introduction

Childbirth and the subsequent postpartum period is an ex-
citing and special life experience for many women. How-
ever, it is also a time of great change, physically, mentally
and socially for mothers, infants and families. While many
mothers and infants transition through this time unevent-
fully, others find it overwhelming or develop significant
health issues that may persist for weeks and months after
giving birth. For example, up to 50% of women report

* Correspondence: w.brodribb@uq.edu.au

Discipline of General Practice, School of Medicine, The University of
Queensland, Royal Brisbane and Women's Hospital, Level 8, Health Sciences
Building, Herston 4029, Australia

(3 BioMed Central

tiredness [1-6] and backache [1-7], while a significant pro-
portion describe headaches [1,3-5,7], perineal [2,3,5,6,8]
and caesarean wound pain [8]. Many women experience
problems such as breast engorgement, sore nipples, mas-
titis, postpartum anxiety, prolonged bleeding and urinary
tract infections [6,9].

Postpartum depression is also common [1-3,6,10] and is
often associated with physical and relationship problems
[10]. Women with postpartum depression are less likely to
attend routine postpartum consultations [11], or to vac-
cinate their children in a timely manner [12]. The infants
of women with depression are more likely to be unsettled

© 2014 Haran et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.Org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.Org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.

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[13] and to have delayed language and behaviour problems
at three years [14].

Women who rate their health as low are more likely
to report symptoms that affect general physical function-
ing and well-being such as tiredness, headache, musculo-
skeletal problems, mastitis, perineal pain and dysuria [5].

Overall, nearly 70% of women describe at least one
physical problem within the first 12 months postpartum
[15]. For 25% of these women the problem is deemed to
be of moderate severity and 20% have severe problems
[15]. As the presence and severity of postpartum prob-
lems increase, there is a corresponding increase in
women's functional limitations including their ability to
work, look after children or undertake household tasks,
and an increase of depressive symptoms [15].

Some infants also experience problems with reports of
hypernatraemic dehydration [16], feeding difficulties [17]
and hospital readmission [18,19] in the early days follow-
ing hospital discharge. Prolonged crying is also one of
the most common reasons for seeking medical care dur-
ing this period [13] with unsettled behaviour being asso-
ciated with high health service utilization [20].

Although childbirth must be considered a normal' part
of life, considering the significant life changes associated
with it and the burden of morbidity in this population, the
aim of care in the postpartum period beyond the immedi-
ate peripartum phase must be 'to detect health problems of
mother and/or baby at an early stage, to encourage breast-
feeding and to give families a good start' [21]. As most
women return to the community within a few days of
birthing, postpartum care is best delivered in a primary
care setting. Therefore it is important that postpartum
care is integrated into primary health care. However, there
appears to be inconsistency about the timing and content
of routine care for mothers and infants in this setting both
between and within countries [21-25].

Although there are some concerns about the practi-
cality of clinical practice guidelines [26], they provide
evidence-based recommendations to improve health
care and outcomes for patients [27]. In the context of
the primary care of women and infants following child-
birth, evidence-based guidelines have the potential to
enhance care and reduce medium and long-term mor-
bidity. As well as offering advice for management in a
clinical situation, guidelines may also have an impact at
a policy level, helping to ensure consistent care across
health care sectors and professions [27]. On the other
hand implementation of guidelines in clinical practice
requires a comprehensive approach including local pol-
icies and contextual issues [28].

The aim of this study was to identify clinical guidelines
that address routine postpartum care in the primary care
setting, to compare their scope and content, and assess
their quality.

Methods

Selection of guidelines

PubMed was searched in December 2012 for articles
published in the previous 10 years using the terms peri-
natal, puerperium, postnatal, postpartum and limited by
clinical guidelines'. Since guidelines are rarely published
in medical journals, a wider search employing guideline
specific databases such as the National Guideline Clear-
inghouse (NGC) and National Institute for Health and
Care Excellence (NICE) was undertaken and relevant
college websites in English-speaking countries including
the Royal College of Obstetricians and Gynaecologists
(RCOG), Royal Australian College of General Practitioners
(RACGP) and the American Academy of Pediatrics (AAP)
were searched for guidelines. Reference lists of identified
guidelines were also searched.

To be included in this study the guidelines had to: in-
clude recommendations on routine postpartum care and
complications arising in the postpartum period; target pri-
mary health care providers; aim at a state or nation-wide
level; outline recommendations for care with directly cited
levels or grades of evidence; include a reference list; and
be available in English full text on the internet. No other
inclusion and exclusion criteria were used.

Comparison of guidelines

Each guideline was summarized by one author (CH) to
identify key points and recommendations. These summar-
ies were checked by other authors for completeness and
accuracy. Direct comparisons of the scope of the guide-
lines within four themes (maternal health, maternal men-
tal health, infant health and breastfeeding) were tabulated
by one author (CH) and then checked by other authors to
ensure they were correct. These broad themes were
chosen to assist with comparisons between guidelines and
to cover the majority of the recommendations within the
all guidelines.

For comparison of the content of the recommendations
and to highlight similarities and differences, five key areas
were selected: timing of routine visits; screening for mood
disorders; maternal health checks; infant health checks;
and promotion of breastfeeding. Where recommendations
differed, the quality and strength of evidence cited was
examined.

Quality assessment

To objectively evaluate the quality of each guideline the Ap-
praisal of Guidelines for Research & Evaluation Instrument
(AGREE II) was used [29]. AGREE II aims to provide a uni-
form framework to assess the quality of guidelines, provide
a methodological strategy for their development, and in-
form what and how information ought to be reported [30].
The instrument consists of 23 items organized into six do-
mains: scope and purpose; stakeholder involvement; rigour

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of development; clarity of presentation; applicability; and
editorial independence. For each item reviewers assign a
score of one to seven depending on how much they agree
or disagree that the guideline conforms with the provided
criteria (1 = strongly disagree, 7 = strongly agree). Using a
similar scale, reviewers assess the overall quality of each
guideline and whether they would recommend the use of
the guideline, with or without modifications.

Two authors (CH and MVD) independently scored
each guideline. Domain scores were calculated by divid-
ing the difference between the obtained score and the
maximum possible score by the difference between the
maximum and the minimum possible score. In keeping
with similar studies, guidelines with scores of less than
50% were deemed to be of low quality [31-33].

Results

Selected guidelines

A total of 626 references were identified by the search.
The titles and abstracts of these articles were reviewed by
CH and 607 references were discarded because they were
not primarily clinical guidelines or their scope did not in-
clude postpartum care in primary care. The full text of a
further 19 references were compared against the inclusion
criteria and another 13 articles were rejected, leaving six
guidelines for inclusion in the review (see Figure 1 and

Table 1). These were: beyondblue 'Depression and related
disorders - anxiety, bipolar disorder and puerperal psych-
osis - in the perinatal period' [34] (Australia); Faculty of
Sexual and Reproductive Health (FSRH) 'Postnatal sexual
and reproductive health' [35] (UK); Institute for Clinical
Systems Improvement (ICSI) 'Preventative services for chil-
dren and adolescents' [36] (USA); National Institute for
Health and Clinical Excellence (NICE) 'Routine postnatal
care of women and their babies' [37] (UK); Royal Australian
College of General Practitioners (RACGP) 'Guidelines for
preventive activities in general practice' [38] (Australia);
and Scottish Intercollegiate Guidelines Network (SIGN)
'Management of perinatal mood disorders' [39] (UK).

The countries from where the guidelines were sourced
have different maternity care systems. In Australia,
women will access their GP or obstetrician/paediatrician
respectively for routine care around 6 weeks. All women
can also visit free Child and Infant Health Nurses regu-
larly from birth, although not all take advantage of the
service. In the USA most women will visit an obstetri-
cian for routine care for themselves and a paediatrician
for the infant, including well-baby checks. In the UK
midwives play a more significant role in the birth and
subsequent postpartum care. Women have access to
midwifery care at home for up to a month and health
visitors for the remaining postpartum period.

Records identified through
database searching
(n= 245)

Additional records identified
through other sources
(n= 381)

Abstracts and titles screened for
relevance
(n = 626)

Articles excluded for lack of
relevance
(n=607)

>

Full-text articles assessed
for eligibility
(n=19)

Studies included in review
(n= 6)

13 full-text articles excluded

• CPGs no reference list
(n=2)

• No LOEs (n=9)

• No guidelines for
recommended care (n=1)

• Incorrect target
audience (n=1)

Figure 1 PRISMA 2009 flow diagram outlining selection process of guidelines for analysis. (CPGs: Clinical Practice Guidelines, LOEs: Levels
of evidence).

Table 1 Selected guidelines - characteristics and scope

Beyondblue - Depression Faculty of Sexual and Institute for Clinical

and related disorders - anxiety, Reproductive Health Systems Improvement

bipolar disorder and puerperal (FSRH) - 'Postnatal (ICSI) - 'Preventative

psychosis - in the perinatal sexual and reproductive services for children

period [34] health' [35] and adolescents' [36]

National Institute for Royal Australian College Scottish Intercollegiate

Health and Clinical of General Practitioners Guidelines Network (SIGN) -

Excellence (NICE) - (RACGP) - 'Guidelines for 'Management of perinatal

'Routine postnatal care preventive activities in mood disorders'. [39]

of women and their general practice' [38]
babies' [37]

Country of origin
and year of
publication

Sponsoring
organisation

Maternal health

Enquiry and
assessment of
physical well-being

Contraception

Maternal mental Enquiry about

health

Infant health

Breastfeeding

emotional well-being

Recommendations
about screening tool

Treatment for
postnatal depression

Enquiry and
assessment of
physical well-being

Information on
healthy parent-infant
relationship

Recommendations

promoting

breastfeeding

Information regarding
the use of medications
during breastfeeding

Australia 201 1

Not-for-profit organization
(government sponsorship)

United Kingdom
2009

Professional body

Psychotropic
medications only

Contraceptive
medications only

USA 2012

Government
organisation

United Kingdom
2006

Government
organisation

V

Australia 201 2 United Kingdom 201 2

Professional body Government organisation

V

Psychotropic
medications only

The guideline has included this topic in the document.

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Scope of the guidelines

The scope of the guidelines, under four broad themes
(maternal health, maternal mental health, infant health
and breastfeeding) is summarised in Table 1.

Maternal health

The NICE [37], RACGP [38] and Faculty of Sexual and
Reproductive Health (FSRH) [35] guidelines all provided
recommendations for this theme with the NICE guideline
being by far the most comprehensive, covering a wide var-
iety of topics. In contrast, the RACGP guideline had only
one recommendation and the FSRH guideline focused
mainly on sexual health issues and contraception.

Maternal mental health

Two guidelines (beyondblue [34] and Scottish Intercollegi-
ate Guidelines Network (SIGN) [39]) focused almost en-
tirely on maternal mental health while another two
(RACGP and NICE) included recommendations for asses-
sing women's emotional wellbeing. The SIGN guideline
discussed maternal mental health in detail under the fol-
lowing sub-heading: predicting and reducing risk; preven-
tion; management; and prescribing issues and a similar
level of detail was provided in the beyondblue guideline.

Infant health

Three of the six guidelines reviewed included a section on
infant health. The NICE, RACGP and Institute for Clinical
Systems Improvement (ICSI) [36] guidelines provided de-
tailed information regarding infant physical examination.
As infant health was the main focus of the ICSI guideline,
it contained the most comprehensive information on this
topic and included recommendations on social issues such
as circumcision and second hand smoke exposure as well
as oral health.

Breastfeeding

All six of the guidelines provided recommendations regard-
ing breastfeeding, although for three guidelines it only re-
lated to maternal medications and the effect on breastfed
infants. Areas covered included breastfeeding promotion
and initiation and common problems mothers' experience.
Some of the recommendations provided by the NICE
guideline applied to in-hospital care and are therefore out-
side the scope of this review.

Key content areas
Timing of routine visits

Under its clinical care pathway the NICE guideline key
recommendations are divided into three time bands -
within 24 hours, between two and seven days and be-
tween two and eight weeks (from day 8 onwards). This
guideline mentions a routine six to eight week postpar-
tum consultation and discusses some of the strengths

and weaknesses of the care currently delivered in this con-
sultation. However, this point is not listed in the overall
recommendations and is graded as a 'good practice point'
indicating it is a recommendation based on expert opinion
and long-standing practice rather than direct evidence.
The ICSI recommends that preventive service' visits
should occur within the first two weeks after birth and at
two, four, six to nine, 12 and 15 months of age. It notes,
however, that there is insufficient evidence to recommend
one visit schedule over another with evidence cited from
two earlier guidelines with recommendations based on
'low quality evidence'. The SIGN, beyondblue, FSRH and
RACGP guidelines do not include clinical care pathways
and timing of routine visits is implied rather than explicit.
For example, the SIGN guideline suggests enquiring about
depressive symptoms postpartum at four to six weeks and
three to four months postpartum, suggesting a visit at that
point in time. Similarly the beyondblue guideline recom-
mends that screening for postpartum depression between
six and 12 weeks after birth during an existing routine
postpartum visit. The only statement in the RACGP
guideline that includes a timeframe is that the first routine
immunisation for a newborn should be at six to eight
weeks.

Screening for mood disorders in the postpartum period

The two Australian guidelines (beyondblue and RACGP)
recommend the use of the Edinburg Postnatal Depression
Scale (EDPS) as a component of the assessment for depres-
sion and co-occurring depression and anxiety in postpar-
tum women. Following a review of the existing literature
(15 articles between 1987 and 2008) which found that the
EPDS had a high sensitivity and specificity and therefore
could be considered an appropriate screening tool, beyond-
blue graded their recommendation 'B'. This means that the
body of evidence can be trusted to guide practice in most
situations. They recommend that screening be undertaken
between six and 12 weeks postpartum.

In contrast, the NICE guideline recommends against
using the EPDS as a screening tool, although it may serve
as part of assessment alongside professional judgement
and clinical interview. The SIGN guideline also only rec-
ommends using the EPDS or Whooley Questions (During
the past month, have you often been bothered by feeling
down, depressed or hopeless? During the past month, have
you often been bothered by having little interest or pleas-
ure in doing things?) to aid clinical monitoring and to fa-
cilitate discussion of emotional issues. Both guidelines
recommend asking women about their emotional well-
being at every visit (NICE) or at least at four to six weeks
and three to four months postpartum, more frequently in
women at high risk (SIGN). Both guidelines use the evi-
dence provided in the National Institute for Health and
Clinical Excellence Antenatal and Postnatal Mental Health

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Clinical Management and Service Guidance [40], to refer-
ence their recommendations.

Maternal health check

Three guidelines contained information about maternal
health checks. The NICE guideline provides detailed rec-
ommendations under subheadings about routine care and
specific problems women may encounter. Topics covered
range from urine and bowel problems and sexual difficul-
ties to tiredness, contraceptive use and maternal diet.
Many of the key recommendations made in the clinical
pathways for postpartum care were 'good practice points'
and were based on expert opinion. The FSRH guideline fo-
cused primarily on sexual health (both physical and men-
tal) and contraception and included recommendations
about opportunistic consultations about pertinent issues
and the need to be able to access appropriate information
and support for women, and to refer when necessary. The
RACGP guideline contained only one recommendation in
this content area; that women should be asked about urin-
ary incontinence on a yearly basis.

Infant health check

Three guidelines (ICSI, RACGP, NICE) contained a num-
ber of age related health checks for newborns and infants.
Many recommendations involved screening for physical
conditions and infant development, haemoglobinopathies,
metabolic and endocrine conditions (e.g. phenylketonuria
and hypothyrodisim) and other congenital problems such
as hearing loss. Preventative counselling for issues includ-
ing SIDS prevention/safe sleeping, non-accidental injury
and immunisation is also recommended. In addition, the
guidelines discuss the benefits of assessing family func-
tioning and parent-infant interactions and providing infor-
mation about available community services. The ICSI
guideline recommends against the use of routine bio-
chemical tests.

Although the recommendations provided were consist-
ent between guidelines, the levels of evidence cited varied
for the same recommendation. For example evidence for
immunisation is given level A by the RACGP and Level 1
by the ICSI guideline, but only a 'good practice point; indi-
cating a lack of good quality evidence supporting the rec-
ommendations, in the NICE guideline.

Promotion of breastfeeding

Three guidelines (RACGP, ICIS, NICE) recommend that
breastfeeding should be supported and promoted regard-
less of the location of care. In addition, the NICE guideline
provides a number of detailed recommendations including
that all health care facilities should have a written breast-
feeding policy that is communicated to all staff and par-
ents. It also recommends that breastfeeding should be
discussed with women at each contact with additional

support being provided if necessary. Breastfeeding progress
should then be assessed and documented in the postnatal
care plan at each contact. Both the SIGN and beyondblue
guidelines only included information on the suitability of
using psychotropic drugs during the breastfeeding period
while the FSRH guideline made recommendations about
contraceptive methods and breastfeeding.

Quality assessment

Five of the six guidelines were able to be reviewed using
the AGREE II criteria. The RACGP guideline did not
provide sufficient information for AGREE II assessment.

Overall, there was a high degree of agreement between
the two independent reviewers' AGREE II scores. This
was reflected in the overall scores, with the average of
all six domains for each guideline being greater than
50%. The only guideline with a domain score deemed to
be low quality (less than 50%) was the editorial inde-
pendence domain in the ICSI guideline. Details for the
scoring for each guideline can be found in Table 2.

All of the guidelines received high scores for describing
their scope and purpose, and stakeholder involvement.
Generally the guidelines used systematic methods to select
evidence and described their criteria for selection in their
final documents. Most guidelines also described the
methods for formulating their recommendations clearly
and generally the recommendations were specific, unam-
biguous and easily identifiable. In comparison to other do-
mains, most guidelines scored poorly in applicability. They
neglected to include information regarding monitoring
and auditing, and details regarding the implementation of
recommendations into practice was rarely covered. All five
guidelines failed to adequately describe how they ensured
that the views of the funding body did not influence the
content of the guidelines. Despite stating how the ICSI has
a transparent policy with regard to disclosing conflicts of
interest, actual conflicts of interest were not disclosed.
Therefore this guideline was the only one to score less
than 50% in any one domain.

Discussion

Only six guidelines from Australia (2), the UK (3) and the
USA (1) met the inclusion criteria and were reviewed.
There was a significant variation in the scope of the guide-
lines with only one guideline encompassing routine post-
partum care for the mother/infant dyad and providing
sufficient detail to enable a practitioner to provide appro-
priate care to women during this period [37]. The other
guidelines only focused on the infant [36], specific post-
partum issues in the mother [34,35,39], or preventative ac-
tivities [38].

The scarcity of comprehensive guidelines for mothers
and infants is a concern because of the stress many
women experience at this time, the high burden of

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Table 2 AGREE II Domain scores of the selected guidelines (Note: the RACGP guidelines were excluded from this table
as insufficient information was provided to score these guidelines using the AGREE II criteria)

Guideline

Beyondblue

FSRH

ICSI

NICE

SIGN

Domain ,

AGREE domain

Scope and purpose (%)

100

67

69

100

97

87

Stakeholder involvement (%)

97

69

56

94

92

82

Rigour of development (%)

95

54

53

79

78

72

Clarity of presentation (%)

97

92

72

89

94

89

Applicability (%)

83

50

52

65

79

66

Editorial independence (%)

75

88

33

67

54

63

Overall mean

91

70

56

82

82

Reviewers recommendations (1-7)

7

4

4.5

7

6

maternal morbidity postpartum [41] and the significant
interplay between the health of the mother and infant.
However, developing wide-ranging, high quality guidelines
is a time and resource intensive activity and this may be
one reason for so few well researched guidelines. In
addition, this finding may be a reflection of a lack of high-
quality research into the most effective care for postpar-
tum women and their infants in the community, especially
as the level of evidence for many of the recommendations
in the NICE guidelines was 'good practice points'.

The lack of evidence is especially apparent when consid-
ering the recommendations for the timing of routine
visits. While two guidelines had explicit timing for visits
(although they were not consistent), the others implied
health professional contact at various times throughout
the postpartum period. The ISCI guideline explicitly states
that there is no evidence that one regime for postpartum
visits is better than another [36]. Other authors also raise
questions about the most appropriate timing of postpar-
tum visits to support, encourage and reassure women and
to prevent, identify and manage issues that may arise
[42-44]. Considering a more mother-centred approach to
the timing of visits, rather than having an all-inclusive rec-
ommendation, may be appropriate. This would require
clear advice to the mother about when to seek assistance
and to the practitioner about the time frame for a visit de-
pending on whether all was going well or not.

In addition, although three guidelines discuss performing
routine examinations on infants, the ISCI again states that
there is no evidence that examining an asymptomatic child
is beneficial in identifying occult disease [36]. However,
these examinations may provide reassurance and an oppor-
tunity to deliver anticipatory guidance to the mother.

There was also inconsistency across guidelines in
regards to the screening of women for postpartum de-
pression with two recommending and two not recom-
mending the use of EPDS. The recommendations in all
four guidelines are the result of systematic reviews of the

literature. However, the review conducted by beyondblue
(on which the RACGP recommendation is based) was
conducted at later point in time than that used by NICE
and SIGN when additional high quality trials of the use
of the tool had been undertaken. These findings stress
the need to update guidelines on a regular basis as new
evidence is accumulated [45] .

Variability between guideline recommendations is not
uncommon [46-48]. Matthys et al. reports that differ-
ences in recommendations could be due to 'insufficient
evidence, different interpretations of the evidence, unsys-
tematic guideline development methods, the influence of
professional bodies, patient preferences, cultural and so-
cioeconomic factors or characteristics of the health care
system [46]. A number of these issues may have had an
impact on the variability seen with the guidelines in this
review. Having a strict process for guideline develop-
ment will go some way to producing more consistent
and high quality guidelines. It is also appropriate to have
evidence-based guidelines that reflect the cultural and
health care systems in a particular region [49,50].

The AGREE II instrument can assist guideline devel-
opers as well as providing a framework for reviewing
quality of guidelines, as was undertaken in this review.
Despite all six guidelines being published after the re-
lease of the AGREE instrument, only one guideline
(RACGP), mentioned its use during guideline develop-
ment. Surprisingly, the RACGP guideline failed to re-
port their methodology sufficiently for reviewers to use
the AGREE II criteria to score the guideline. As noted
by Greuter et al. [32], one would assume that guideline
developers are aware of the AGREE instrument and up-
to-date with the literature about reporting the method-
ology of guideline development [32]. The possibility that
guidelines of high methodological quality score poorly
on the AGREE II instrument due to failed reporting,
highlights the need for authors to consider and report
quality measures when developing the guidelines.

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Similar to prior reviews of guidelines, applicability and
editorial independence domains scored the lowest [31,32].
In the case of editorial independence, low scores were
mostly assigned due to authors failing to adequately report
their methodology. Given that implementation is the key
objective of most guidelines there needs to be an improve-
ment in the applicability domain in future revisions of
guidelines. It was also concerning to see the FSRH guide-
line failing to provide a procedure for updating its recom-
mendations considering the importance of guidelines
remaining up-to-date.

Limitations

One limitation of the study was the exclusion of guidelines
that were not available to download over the internet.
However, guidelines are there to guide clinical practice
and need to be readily available to those who need them.
Another limitation was the inclusion of English language
guidelines only. This may have led to the exclusion of
other relevant guidelines, designed for use in areas such as
continental Europe and Asia that may have brought a dif-
ferent cultural perspective to the review. Although at-
tempts were made to obtain all guidelines that fitted the
inclusion criteria, some may have been missed if they were
not retrieved with the search terms used.

Conclusion

Clinical practice guidelines provide an avenue for practi-
tioners to access critically-evaluated evidence-based rec-
ommendations for the care of their patients. This review
found only six guidelines from the international literature
that satisfied the selection criteria and addressed out-of-
hospital maternal and infant care in the postpartum
period. Despite the quality of the guidelines and the simi-
larity of recommendations, only one guideline covers rou-
tine postpartum care for the mother and infant. It is
important that the mother and infant be seen as a unit,
particularly in the first few months of life, because what af-
fects one inevitably affects the other. It is also important
not to position normal postpartum care within an illness
framework when most women and infants have an un-
eventful course. Further research into care within the
postpartum period is warranted as many recommenda-
tions, such as timing of visits and maternal and infant ex-
aminations, are not backed up by high levels of evidence,
often relying on historical models of care and the status
quo. In addition, there needs to be increased rigor into
formulating guidelines, or at least in reporting the devel-
opment of guidelines - especially with regard to editorial
independence and mechanisms to up-date the guidelines.

Abbreviations

AAP: American Academy of Pediatrics; AGREE II: Appraisal of guidelines for
Rrsearch & evaluation instrument; EDPS: Edinburg postnatal depression scale;
ICSI: Institute for clinical systems improvement; NGC: National guideline

clearinghouse; NICE: National Institute for Health and Care Excellence;
RACGP: Royal Australian College of General Practitioners; ROCG: Royal
College of Obstetricians and Gynaecologists; SIGN: Scottish Intercollegiate
Guidelines Network; UK: United Kingdom; USA: United States of America.

Competing interests

The authors have no competing interests.

Authors' contributions

CH participated in the design of the study, undertook the literature search,
summarised the guidelines, assessed the guidelines for quality and wrote the
majority of first draft of the manuscript. MVD conceived and participated in
the design of the study, reviewed the literature search and guideline
summaries, assessed the guidelines for quality and reviewed and revised the
manuscript. BM conceived and participated in the design of the study,
reviewed the literature search, guideline summaries and quality assessment
and reviewed and revised the manuscript. WB conceived and participated in
the design of the study, reviewed the literature search, guideline summaries
and quality assessment, contributed to the first draft of the manuscript and
edited subsequent drafts. All authors read and approved the final
manuscript.

Acknowledgements

The researchers gratefully acknowledge the RACGP Foundation for their
support of this project through the Family Medical Care, Education and
Research Grant. CH was funded by the University of Queensland's Summer
Scholar Program.

Received: 20 September 2013 Accepted: 27 January 2014
Published: 29 January 2014

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doi:1 0.1 1 86/1 471 -2393-1 4-5 1

Cite this article as: Haran et al.: Clinical guidelines for postpartum
women and infants in primary care-a systematic review. BMC Pregnancy
and Childbirth 2014 14:51.

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